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Internal Medicine > JH IM Board Review - Disorders of the Small and Large Intestine II > Flashcards

JH IM Board Review - Disorders of the Small and Large Intestine II Flashcards

1
Q

Mastocytosis as secretory diarrhea - Extraintestinal manifestations:

A
  1. Pruritus.
  2. Flushing.
  3. Abdominal pain.
  4. Headache.
  5. Urticaria pigmentosa ==> Macular lesions that urticate when stroked (Darier sign).
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2
Q

Mastocytosis as secretory diarrhea - Diagnosis:

A
  1. Elevated 24h urine for histamine and metabolites.
  2. Elevated serum tryptase levels.
  3. Skin Bx.
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3
Q

Mastocytosis as secretory diarrhea - Tx:

A
  1. H blockers.

2. Glucocortico.

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4
Q

Constipation - More common in men or women?

A

WOMEN.

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5
Q

Constipation - Dx and evaluation - What to suspect from Hx/PEx:

A

==> Look for 2o causes of constipation.

==> Hx may point to low fiber intake or new medications.

==> Rectal exam may point to ANORECTAL dysfunction.

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6
Q

Constipation - Dx and evaluation - What to order?

A
  1. CBC.
  2. Electrolytes.
  3. Ca.
  4. TSH.
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7
Q

Constipation - Dx and evaluation - What to order in problematic cases?

A
  1. Abdominal Radiograph.
  2. Colonic transit studies.
  3. Colonoscopy ==> For those with a change in bowel habits, those who are elderly, or those who have not received their screening examinations.

==> ANORECTAL MOTILITY testing can be considered AFTER INITIAL Tx is tried.

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8
Q

Constipation - Dx and evaluation - Constipation is often caused by …?

A

Slow transit time.

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9
Q

Constipation - Dx and evaluation - With pelvic floor dysfunction?

A

Straining is a dominant symptom and soft stool and even enemas may be difficult to pass.

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10
Q

Constipation - Tx of FUNCTIONAL CONSTIPATION:

A
  1. Hydration.
  2. Exercise.
  3. Dietary fiber (15-25g/day).
  4. Consider osmotic laxatives (eg polyethylene glycol, lactulose, sorbitol).
  5. Reserve stimulant laxatives (eg bisacodyl, senna) for acute constipation.
  6. Psychological counseling.
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11
Q

Constipation - Tx for pelvic floor dysfunction:

A
  1. Enemas.
  2. Physical therapy.
  3. Biofeedback.
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12
Q

IBS affects what percentage of Western adults?

A

20%.

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13
Q

IBS is the 2nd leading cause of …?

A

Absenteeism ==> Next to common cold.

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14
Q

Postinfectious IBS?

A

Infection may predispose to IBS.

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15
Q

Rome III criteria for IBS:

A

Symptoms of recurrent abdominal pain or discomfort and a marked change in bowel habit for at least 6 months, with symptoms experienced on at least 3 days of at least 3 months. AT LEAST 2 of the following must apply:

  1. Pain is relieved by a bowel movement.
  2. Onset of pain is related to a change in frequency of stool.
  3. Onset of pain is related to a change in the appearance of stool.
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16
Q

IBS - Diagnosis and evaluation - With diarrhea-predominant IBS, need to rule out …?

A
  1. Lactose intolerance.
  2. Celiac disease.
  3. IBD.
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17
Q

IBS - Diagnosis and evaluation - If constipation is severe, r/o:

A
  1. Hypothyroidism.
  2. HypoPARAthyroidism.
  3. Diverticulosis.
  4. Anorectal dysfunction.
  5. Malignancy.
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18
Q

IBS - Diagnosis and evaluation - Occasionally, pelvic pain and altered bowel habit with gyn conditions, such as endometriosis, can mimic IBS:

A

Be wary of pts with risk factors for ovarian cancer.

==> A thorough age-appropriate gyn evaluation should be considered as required before making a diagnosis of IBS.

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19
Q

IBS Tx - Educate pt:

A

THE CONDITION IS BENIGN.

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20
Q

IBS Tx - Adding soluble fiber in the diet:

A

Can help.

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21
Q

IBS Tx - Reducing or remove offending foods:

A

High-fat/High-carb.

==> Some reported benefits when reducing foods containing FODMAP (Fermentable Oligo-Disaccharides, Monosaccharides and Polyols).

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22
Q

IBS Tx - Antispasmodics:

A
  1. Dicyclomine.
  2. Hyoscyamine.
  3. Low-dose TCAs.

==> Helpful for abdominal pain by reducing spasm and hypersensitive, respectively.

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23
Q

IBS Tx - Antimotility agents:

A

Loperamide ==> May be helpful for diarrhea.

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24
Q

IBS Tx - Probiotics:

A

Have been used in small trials ==> Particularly for post-infectious IBS.

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25
Q

IBS - Tx - Gas symptoms may respond to:

A
  1. Diet changes.
  2. Simethicone.
  3. Bismuth.
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26
Q

IBS Tx - Avoid:

A

Narcotics and benzos.

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27
Q

IBS Tx - Drugs:

A
  1. Linzess.
  2. Amitiza.
  3. Prucalopride.
  4. Tegaserod (removed).
  5. Alosetron.
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28
Q

IBS Tx - Linzess:

A

A guanylate cyclase C agonist indicated for constipation-predominant or pain-dominant IBS-C.

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29
Q

IBS Tx - Amitiza:

A

A Cl-channel agonist indicated for constipation-predominant or IBS-C.

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30
Q

IBS Tx - Prucalopride is approved in …?

A

Europe, not yet in USA.

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31
Q

IBS Tx - Alosetron:

A

5-HT-3 AGONIST.

==> Modulates visceral afferent activity from the GI tract and was found to be helpful in IBS in women with diarrhea-predominant symptoms.

32
Q

IBS Tx - Alosetron - Problem:

A

Can be prescribed through a special postmarketing program to dedicated registered prescribers, but is NOT in general use because of reported episodes of ISCHEMIC COLITIS.

33
Q

IBD - Smoking as a risk factor:

A
  1. Incr. risk in CD.

2. Decr. risk of current smokers + increased risk of ex-smokers in UC.

34
Q

IBD - Causes of exacerbation:

A
  1. Usually NOT identifiable.

2. NSAID use + Tobacco use (in CD), infections, and medication noncompliance may predispose to attacks.

35
Q

IBD and cancer - COLORECTAL:

A
  1. Related to DURATION + EXTENT of disease.
  2. Overall risk in UC and EXTENSIVE COLITIS from CD is 2-5%.
  3. Screen for dysplasia and cancer beginning 8 to 10yrs after diagnosis of IBD is made, then every 1 to 2 years.

==> SMALL-BOWEL CANCER risk incr. in CD.

36
Q

IBD - Dx and evaluation - Lab to look for:

A
  1. Incr. CRP + ESR.
  2. Leukocytosis.
  3. Anemia.
  4. Thrombocytosis.
  5. Fecal CALPROTECTIN elevated.
37
Q

IBD - Dx and evaluation - Stool studies to r/o INFECTION:

A
  1. Ova and parasites.
  2. C.difficile.
  3. Culture.
38
Q

IBD - Dx and evaluation - Antibodies to order:

A
  1. Peripheral antineutrophil cytoplasmic antibody (p-ANCA) is elevated in 60% of pts with CD or UC.
  2. ASCA in 80% of CD.

==> NEITHER IS ADEQUATE TO Dx, but in some cases of indeterminate colitis, antibodies can help guide Dx.

39
Q

IBD - Dx and evaluation - Radiographic features:

A
  1. Barium enema can show mucosal granularity or ulceration.
  2. Small-bowel series may show ulcerations in between normal mucosa, fistulas (“cobblestoning”), or strictures (CD).
  3. MRI enterography helpful for CD of small intestine.
  4. MRI of the pelvis is helpful in evaluating rectal or perirectal disease and fistula.
  5. CT scan of abdomen and pelvis or CT enterography can also be useful in some cases.
40
Q

IBD - Dx and evaluation - What procedures are commonly used to make the diagnosis and to distinguish between UC and colonic CD?

A

Sigmoidoscopy or colonoscopy.

41
Q

IBD - Dx and evaluation - Capsule endoscopy:

A

Useful for staging or identifying small-bowel CD.

42
Q

IBD - Assessment of severity of a disease flare - Mild to moderate:

A
  1. Able to tolerate oral diet.
  2. No dehydration.
  3. No toxicity.
  4. NO Abdominal tenderness.
  5. NO Mass or obstruction.
  6. For UC, less than 4 stools per day.
43
Q

IBD - Assessment of severity of a disease flare - Moderate to severe:

A
  1. Failed treatment for mild to moderate disease or symptoms of fever, weight loss, abdominal pain and tenderness.
  2. Intermittent nausea.
  3. Vomiting.
  4. Anemia.
  5. Moderate UC (greater than 4 stools per day).
  6. Severe UC (greater than 6 stools per day + signs of toxicity).
44
Q

IBD - Assessment of severity of a disease flare - Severe:

A

FULMINANT.

  1. Persistent symptoms despite treatment with steroids or high temp, persistent vomiting, intestinal obstruction, rebound tenderness, cachexia, or abscess.
  2. Fulminant UC ==> Greater than 10 bloody stools per day, with signs of toxicity; tenderness, distention, dilated colon, fever, tachycardia.
45
Q

IBD - Extra-intestinal manifestations and complications of IBD - Arthritis:

A
  1. Peripheral arthritis involving large joints.

2. Spondyloarthropathy/ ankylosing spondylitis.

46
Q

IBD - Extra-intestinal manifestations and complications of IBD - Skin:

A
  1. Pyoderma gangrenosum.

2. Erythema nodosum.

47
Q

IBD - Extra-intestinal manifestations and complications of IBD - Hepatobiliary manifestations:

A
  1. PSC (70% of PSC pts have IBD). All PSC pts should be screened for IBD with colonoscopy.
  2. Cholelithiasis.
48
Q

IBD - Extra-intestinal manifestations and complications of IBD - Fistulas (CD):

A
  1. Often involves perianal area, but any area of bowel may be involved, can lead to abscess formation.
  2. Usually extend to skin, bowel, or vagina.
49
Q

IBD - Extra-intestinal manifestations and complications of IBD - Bowel obstruction/perforation:

A
  1. Stricturing can lead to obstruction.
  2. Spontaneous perforation more common in CD.
  3. Toxic megacolon ==> Abdominal distention, diarrhea, colonic dilation on radiograph. (More common in UC).
  4. Fever, tachycardia, leukocytosis, anemia.
  5. 50% of pts will require surgery.
  6. 15% mortality rate.
50
Q

IBD - Extra-intestinal manifestations and complications of IBD - OTHER:

A
  1. Hemorrhage.
  2. Malabsorption.
  3. Dehydration.
  4. Anemia (iron deficiency, B12 def.).
  5. Osteoporosis.
  6. Thromboembolism.
  7. Spontaneous abortion/premature delivery.
  8. Protein-losing enteropathy.
  9. Nephrolithiasis.
  10. Amyloid.
  11. CRC.
51
Q

IBD - Extra-intestinal manifestations and complications of IBD - Osteoporosis:

A

Can occur even without corticosteroid use.

==> Bone density scans should be checked routinely.

52
Q

IBD - Extra-intestinal manifestations and complications of IBD - Nephrolithiasis:

A

CALCIUM OXALATE + URATE STONES.

53
Q

IBD - Tx - Medical management:

A
  1. 5-ASA medications ==> Sulfasalazine, mesalamine, olsalazine.
  2. Corticosteroids.
  3. ABX.
  4. Immunosuppressants.
54
Q

IBD - Tx - 5-ASA:

A
  1. Mainstay of therapy for mild to moderate cases of UC and CD.
  2. Inhibit lipoxygenase path + PG cytokine synthesis + Free radical scavengers.
55
Q

IBD - Tx - Corticosteroids:

A

INITIAL Tx for moderate cases and all severe cases.

  1. Can be used IV, orally, or as an enema (for isolated rectal involvement or proctitis).
  2. Oral budesonide undergoes extensive 1st-pass metabolism and has fewer side effects.
56
Q

IBD - Tx - Abx:

A

MNZ, Ciprofloxacin:

  1. NO CLEAR ROLE IN Tx of UC.
  2. MOST EFFECTIVE in fistulizing and perianal disease of CD.
  3. Some role suggested in postoperative care to prevent recurrence.
57
Q

Immunosuppressants - 2 categories:

A
  1. NON biologic agents.

2. Biologic agents.

58
Q

Immunosuppressants - Used to …?

A

Spare steroid use in pts who have moderate to severe disease.

==> Most commonly indicated in steroid-resistant or steroid-dependent pts.

59
Q

Immunosuppressants - NON biologic agents:

A
  1. Aza/6-mp.
  2. Cyclosporine.
  3. Mtx.
60
Q

Aza/6-mp:

A

MOST FREQUENTLY USED.

==> Both to induce and to maintain remission.

61
Q

Cyclosporine:

A

Used in some cases for UC, NOT CD.

==> Given over 2-4 months to induce remission.

62
Q

MTX:

A

MAINLY FOR CD.

63
Q

Biologic agents are used …?

A

Alone or in combination with aza/6-mp to induce and maintain remission.

64
Q

Biologic agents - Anti-TNF:

A
  1. Infliximab.
  2. Adalimumab.
  3. Certolizumab.
65
Q

Infliximab:

A

CHIMERIC mouse/human monoclonal antibody against TNF-alpha.

==> Given IV infusion for both CD and UC to induce and maintain remission; also used to treat FISTULIZING CD.

66
Q

Adalimumab:

A

Recombinant human IgG1 against TNF.

==> Subcutaneous administration every 2 WEEKS.

==> Can be used in pts who have lost response to infliximab.

67
Q

Certolizumab:

A

Humanized monoclonal antibody Fab fragment linked to polyethylene glycol, which neutralizes TNF.

==> Subcutaneous administration every 4 WEEKS.

68
Q

Biologic agents - Newer integrin therapies:

A
  1. Natalizumab.
  2. Vedolizumab.
  3. Ustekinumab.
69
Q

Natalizumab:

A

Alpha-4 integrin antibody.

PML risk. JC virus screening.

70
Q

Vedolizumab:

A

a4b7 integrin antibody that blocks leukocytes from binding and traveling to the gut.

==> Approved for UC and CD in adults with MODERATE to SEVERE disease.

71
Q

Biologic agents - Pts require screening for:

A
  1. TB.
  2. HBV.
  3. Lymphoma risk is also slightly increased + Risk for demyelinating disease, hematologic disease, liver tox.
72
Q

IBD - Tx - Surgical - UC:

A

Because UC is limited to the colon, TOTAL PROCTOCOLECTOMY cures UC.

==> An ileal pouch can be formed, replacing the rectum.

==> This can be affected by POUCHITIS.

73
Q

IBD - Tx - Surgical - UC - Indications for surgery:

A
  1. Fulminant disease (toxic megacolon).
  2. Colitis refractory to medical therapy.
  3. Dysplasia or concern for CRC cancer.
  4. Stricture.
  5. Massive bleeding.
74
Q

IBD - Tx - Surgical - CD - Indications:

A
  1. Obstructive symptoms.
  2. Refractory severe inflammation.
  3. Repair of fistulas.
75
Q

Surgery for CD:

A

More than 40% of pts require surgery within first 10yrs of diagnosis.

==> Up to 80% will have evidence of RECURRENCE endoscopically.

==> 10-15% will have clinical recurrence.

76
Q

Nutritional therapy (enteral therapy) for CD:

A
  1. Effective in pts with active CD for treating and decreasing fistula output.
  2. Useful in children, but adults can find enteral therapy unpalatable.
  3. NOT effective as lone therapy in UC.

Internal Medicine (107 decks)

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